CPCP: Acute Lithium Toxicity by Crack Medical Students

Nandita Agarwal, M3
Andrew Jesson, M3

We got an outstanding Clinical Problems in Consultation Psychiatry (CPCP) presentation today on acute lithium toxicity from a couple of medical students on crack. No wait, I mean a couple of crack medical students! They worked really hard on it and it’s excellent. They’re in their 3rd year clerkship. Nandita Agarwal is interested in either surgery or internal medicine. Andrew Jesson is targeting either emergency medicine or Obstetrics-Gynecology.

Acute lithium toxicity is an issue for consulting psychiatrists less frequently nowadays, probably influenced by the FDA approval of a number of atypical antipsychotics for bipolar disorder. Lithium requires a fair amount of prescribing knowledge especially regarding dose titration, serum level monitoring, and informed consent discussion with patients to name a few.

The indication for lithium is mainly for treating and preventing mania in patients with bipolar affective disorder. It also has some support in the literature for having anti-suicide properties. Lithium is also used to augment antidepressants.

Consultants from psychiatry, nephrology, and neurology are called to help manage acute toxicity, and the more severely ill patients need to be monitored in the intensive care unit.

Patients who are severely toxic on lithium acutely tend to be delirious, which makes it very challenging to assess underlying primary psychiatric illness. If they don’t need critical care unit management, an ideal place to stabilize them and restart lithium (if there’s no medical contraindication to that) is on a combined specialty unit, like the Medical-Psychiatry Unit at The University of Iowa Hospitals & Clinics.

It’s kind of tough finding any newly minted psychiatrists who know much about lithium these days, which Dr. Ron Pies (one of the commenters) lamented after reading the April Psychiatric Times article “Tips, Cautions, and Successes in Treating Bipolar Patients with Lithium” (hey, registration is free to read this helpful review in the tweet below!). You might ask, “who you gonna call?” when lithium toxicity becomes an issue and this crops up partly because there are so many new drugs for the treatment of bipolar disorder. Everybody wants a new drug and while Lithium has side effects, it’s still an effective treatment.


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